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NRS133: Unit 6 - Shock > Shock > Flashcards

Shock Flashcards

1
Q

Shock

A

widespread abnormal cellular metabolism that occurs when oxygenation and tissue perfusion needs are not met to the level necessary to maintain cell function.

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2
Q

The 2 main problems of shock are

A

Lack of Oxygen and Tissue Perfusion

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3
Q

Causes of Hypoxia

A
  • decreased hemoglobin
  • decreased concentration of oxygen in air
  • inability of tissues to extract oxygen from the blood
  • decreased diffusion of oxygen from alveoli
  • impaired ventilation
  • poor tissue perfusion.
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4
Q

Shock is a…..

A

Condition not a disease.

If left untreated can lead to fatal cardiac dysrhythmias

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5
Q

Cardiac dysrhythmias start as and advance to…

A

Ventricular tachycardia > V Fib >Asystole (flat line)

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6
Q

Tissue Perfusion

A

delivery of blood to the capillary bed in tissues

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7
Q

SVR

A

Systemic vascular resistance

-Vasodialation or vasoconstriction

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8
Q

Info about blood flow to organs

A

Blood flow to organs varies according to need. The body can selectively increase bloodflow to some organs and decrease others. This is called shunting of blood

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9
Q

Shunting of blood

A

Blood is shut off from peripheral limbs to facilitate better blood flow to vital organs

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10
Q

MAP

A

Mean Arterial Pressure
The arterial blood pressure (between 60 and 70 mmHg) necessary to maintain perfusion of major body organs, such as the kidneys and brain.

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11
Q

CO

A

Cardiac Output
The volume of blood ejected by the heart each minute (from Left Ventricle to tissues) ; normal range in adults is 4-7 L/Min

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12
Q

SVR

A

Systemic Vascular Resistance
The resistance to the flow of blood through the body’s blood vessels; it increases when vessels constrict and decreases when vessels dilate.

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13
Q

EF

A

Ejection Fraction

The percentage of blood ejected from the heart during systole

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14
Q

Preload

A

The degree of myocardial fiber stretch at the end of diastole and just before contraction; determined by the amount of blood returning to the heart from both the venous system (right heart) and the pulmonary system (left heart)

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15
Q

Afterload

A

The pressure or resistance that the ventricles must overcome to eject blood through the semilunar valves and into the peripheral blood vessels; the amount of resistance is directly related to arterial blood pressure and blood vessel diameter.

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16
Q

Starling’s Law of the Heart

A

The more the heart is filled during diastole (within limits), the more forcefully it contracts.

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17
Q

Calculating MAP

A

MAP= DBP + 1/3(SBP-DBP)

Normal MAP is 93mmHg

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18
Q

What is the minimum MAP needed to perfuse vital organs

A

60 - 70 mmHg

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19
Q

What starts shock

A

Problems with oxygen delivery.

hypoxia> cell/tissue death> MODS> Death

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20
Q

Which patients are at highest risk for Shock?

A

Those in the acute care setting

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21
Q

MODS

A

Multiple Organ Dysfunction Syndrome
The sequence of inadequate blood flow to body tissues, which deprives cells of oxygen and leads to anaerobic metabolism with acidosis, hyperkalemia, and tissue ischemia; this is followed by dramatic changes in vital organs and leads to the release of toxic metabolites and destructive enzymes.

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22
Q

Titration Math

A

Total Dose Hourly Dose
________ = ___________
Total Volume Hourly Volume

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23
Q

Hypovolemic Shock Overall Cause

A

Total body fluid decrease ( in all fluid compartments)

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24
Q

Specific Cause or Risk Factors of Hypovolemic Shock

A

Hemorrhage
-Trauma, GI ulcer, Surgery, Inadequate Clotting
Dehydration
-Vomiting, Diarrhea, Heavy diaphoresis, Diuretic therapy, NG suction, Diabetes, Hyperglycemia

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25
Q

Overall Cause of Cardiogenic Shock

A

Direct pump failure (fluid volume not affected)

Usually caused by a blockage of coronary artery which leads to tissue necrosis

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26
Q

Specific Cause or Risk Factors of Cardiogenic Shock

A 
Myocardial infarction
Cardiac arrest
Ventricular dysrhythmias 
Cardiac amyloidosis
Cardiomyopathies
Myocardial Degeneration
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27
Q

Overall Cause of Distributive Shock

A

Fluid shifted from central vascular space (total body fluid volume normal or increased)

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28
Q

Specific Cause or Risk Factors of Distributive Shock

A 
Neural Induced
- Pain
- Anesthesia
- Stress
- Spinal cord injury
- Head Trauma
Chemical Induced 
- Anaphylaxis
- Sepsis
- Capillary leak (burns, extensive trauma, liver impairment, hypoproteinemia)
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29
Q

Overall Cause of Obstructive Shock

A

Cardiac function decreased by noncardiac factor (indirect pump failure). Total body fluid is not affected although central volume is decreased.

30
Q

Specific Cause or Risk Factors of Obstructive Shock

A 
Cardiac tamponade
Arterial stenosis
Pulmonary embolus
Pulmonary hypertension
Constrictive pericarditis
Thoracic tumors
Tension pneumothorax
31
Q

Cardiovascular Manifestations of Shock

A
  • Decreased cardiac output
  • Increased Pulse
  • Thready Pulse
  • Decreased B/P
  • Narrowed pulse pressure
  • Postural hypotension
  • low central venous pressure
  • flat neck and hand veins in dependent positions
  • slow capillary refill in nail beds
  • diminished peripheral pulses
32
Q

Respiratory Manifestations of Shock

A
  • Increased respiratory rate
  • Shallow depth of respiration
  • Increased Paco2
  • Decreased Pao2
  • cyanosis, especially around lips and nail beds
33
Q

Early Neuromuscular manifestations of Shock

A
  • Anxiety
  • Restlessness
  • Increased thirst
34
Q

Late Neuromuscular manifestations of Shock

A
  • Decreased CNS activity (lethargy to coma)
  • Generalized muscle weakness
  • Diminished or absent deep tendon reflexes
  • Sluggish pupillary response to light
35
Q

Kidney Manifestations of Shock

A
  • Decreased urine output
  • Increased specific gravity
  • Sugar and acetone present in urine
36
Q

Integumentary Manifestations of Shock

A
  • Cool to cold
  • Pale to mottled to cyanotic
  • Moist, clammy
  • Mouth dry; pastelike coating present
37
Q

Gastrointestinal manifestations of Shock

A
  • Decreased motility
  • Diminished or absent bowel sounds
  • Nausea and vomiting
  • Constipation
38
Q

Classifications of Shock

A
  • Hypovolemic
  • Cardiogenic
  • Obstructive
  • Distributitve
39
Q

Septic Shock falls under which category

A

Distributive Shock

40
Q

Spinal Shock falls under which category

A

Distributive Shock

41
Q

Common problems leading to hypovolemic shock are…

A

hemorrhage and dehydration

42
Q

Hemodilution

A

causes the APPEARANCE of a decrease of HGB and HCT levels.

43
Q

Serum Lactic Acid

A

3 - 7 mg/dL

Show if heading into acidosis from anaerobic metabolism.

44
Q

Stages of Shock

A
  1. Initial stage
  2. Nonprogressive stage
  3. Progressive stage
  4. Refractory stage
45
Q

Adaptive responses of Initial Stage

A
  • Decrease in baseline mean arterial pressure (MAP) of 5 - 10 mmHg
  • Increase sympathetic stimulation
  • Mild vasoconstriction
  • Increased heart rate
46
Q

Adaptive responses of Nonprogressive Stage

A
  • Decrease in MAP of 10-15 mmHg from the patient’s baseline
  • Continued sympathetic stimulation
  • Moderate vasoconstriction
  • Increased HR
  • Decreased pulse pressure
  • Chemical compensation (Renin, aldosterone, and antidiuretic hormone)
  • Increased vasoconstriction
  • Decreased urine output
  • Stimulation of thirst reflex
  • Some anerobic metabolism in nonvital organs
  • Mild acidosis
  • Mild hyperkalemia
47
Q

Adaptive responses of Progressive Stage

A
  • Decrease in MAP of >20 mmHg from the patient’s baseline
  • Anoxia of nonvital organs
  • Hypoxia of vital organs
  • Overall metabolism is anaerobic
  • Moderate acidosis
  • Moderate hyperkalemia
  • Tissue ischemia
48
Q

Adaptive responses of Refractory Stage

A
  • Severe tissue hypoxia with ischemia and necrosis
  • Release of myocardial depressant factor from the pancreas
  • Buildup of toxic metabolites
  • Multiple organ dysfunction syndrome (MODS)
  • Death
49
Q

O2 Saturation with Stages of Shock

A

Nonprogressive - 90-95%
Progressive - 75-80%
Refractory - Below 70%

50
Q

Hematocrit Range

A

Females: 37 - 47%
Males: 42 - 52%

51
Q

Hemoglobin Range

A

Females: 12-16 g/dL
Males: 14 - 18 g/dL

52
Q

What fluid should you give for acidosis

A

LR

53
Q

Best Practice Treatment of Hypovolemic Shock

A
  • Ensure patent airway
  • start and IV catheter
  • administer oxygen
  • elevate the pts feet, keeping head flat or no more than 30 degrees
  • examine for overt bleeding (if present apply direct pressure)
  • administer drugs as prescribed
  • Increase the rate of IV fluid delivery
  • Do Not leave the patient
54
Q

Dopamine

A

Vasoconstrictor
Sympathomemetic
Improve blood flow by increasing peripheral resistance, increasing venous return to the heart, and improving myocardial contractility

55
Q

Sodium nitroprusside

A

Agent to enhance myocardial perfusion
Nitrates
Improves blood flow to the myocardium by dilating the coronary arteries This effect is primary and rapid but short.

56
Q

Sodium nitroprusside

Nursing considerations and rationales

A
  • Protect contained from light. (Light degrades drug quickly)
  • Assess BP q15mins (the vasodilating effect can cause systemic vasodilation and hypotension especially in older adults.
57
Q

Dopamine

Nursing considerations and rationales

A
  • Assess the patient for chest pain (Drug increases myocardial oxygen consumption)
  • Monitor urine output hourly (Higher doses decrease renal perfusion and urine output
  • Assess B/P q15mins (Hypertension is a sign of overdose)
  • Assess for headache. ( Headache is an early symptom of drug excess
  • Assess q30mins for extravasation and check extremities for color and perfusion. ( If the drug gets into the tissues, it can cause severe vasoconstriction, tissue ischemia, and tissue necrosis.
  • Assess for chest pain ( Drug can cause rapid onset of vasoconstriction in the myocardium and impair cardiac oxygenation
58
Q

Milrione & Dobutamine

A

Inotropic Agents
Directly stimulate adrenergic receptor sites on the heart muscle (beta, receptors) and improve heart muscle cell contraction

59
Q

Milrione & Dobutamine

Nursing considerations and rationales

A
  • Assess for chest pain (Drug increases myocardial oxygen consumption and can cause angina or infarction)
  • Assess B/P q15 mins (Hypertension is a sign of overdose
60
Q

Collateral circulation in the heart…

A

increases over age because of compensation from athrosclerosis.

61
Q

Ventricular Tachycardia…

A

seen in heart ischemia, leads to V-fib (3-5 mins), but is a shockable rhythm.

62
Q

Septic Shock

A
  • decreased BP
  • increased respirations and heartrate
  • low urine output
63
Q

Progression of infection in Septic Shock

A

Local infection> Systemic Infection> SIRS (Systemic inflammatory response syndrome) > Organ failure (severe sepsis) > multiple organ system failure (MODS) (septic shock) > Death.

64
Q

Important consideration of Blood Cultures

A

Collect them before hanging IV!

65
Q

SIRS criteria

A

-Temp of more than 100.4 or less than 96.8
- HR >90 BPM
- RR >20BPM or PaCO2 12 or <4
- Sepsis is considered present if two or more SIRS criteria are present along with any known infection and one or more of these clinical manifeststions:
Hypotension, Decreased urine output, Positive fluid balance, Decreased capillary refill, Hyperglycemia, Unexplained changed in mental status, Rising creas level.

66
Q

Conditions predisposing to sepsis and septic shock

A
  • malnutrition
  • immunosuppression
  • large, open wounds
  • mucous membrane fissures in prolonged contract with bloody or drainage soaked packing
  • GI ischemia
  • Exposure to invasive procedures
  • Malignancy
  • Older than 80
  • Infection with resistant organisms
  • Receiving chemo
  • alcoholism
  • diabetes mellitus
  • chronic kidney disease
  • transplantation recipient
  • hepatitis
  • HIV/AIDS
67
Q

Septic Shock

A

the stage of sepsis and SIRS when multiple organ failure is evident and uncontrolled bleeding occurs. Greater than 50% death rate.

68
Q

Risk factors of Hypovolemic shock

A
  • Diuretic therapy
  • Diminished thirst reflex
  • immobility
  • use of aspirin-containing products
  • use of complimentary therapies such as Ginko Biloba
  • Anticoagulant therapy
69
Q

Risk factors for Cardiogenic shock

A
  • Diabetes mellitus

- Presence of cardiomyopathies

70
Q

Risk factors of Distributive Shock

A
  • Diminished immune response
  • Reduced skin integrity
  • Presence of cancer
  • Peripheral neuropathy
  • Strokes
  • Institutionalization
  • Malnutrition
  • Anemia
71
Q

Risk of Obstructive Shock

A
  • Pulmonary hypertension

- Presence of cancer

72
Q

Pulmonary Capillary Wedge Pressure

A

2-15 mmHg

NRS133: Unit 6 - Shock (1 decks)

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